4170NO`TE•., �
With proper,validation
this form constitutes -an -
encroachment permit
CITY OF LA QUINTA
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the, construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other'like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
25 2004 Subdivision Improvement Permit— Class III
DATE:June . • Minor Improvement Permit Class IV
LOCATION OF CONSTRUCTION Jefferson & Avenue 50 — On Jefferson (West side)
(Street address or Description of Location)
PURPOSE OF CONSTRUCTION Open & Close gate valves Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Ensure gate valves are open
*See Attached Spee4al—Gesidktions*
DIMENSION OF INSTALLATION OR REMOVAL NSA
SIZE OF EXCAVATION, IF NEEDED NSA
APPROXIMATE TIME WHEN WORK WILL BEGIN Juke 26, 2004 r ., ,, k tNY 1 l C
APPROXIMATE TIME OF COMPLETION June Z , 2004
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com-
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to:
Indemnify,defend• and save the City, its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting .from claims or court action and arising out of any accident, loss or damage to persons or property
happening -or occurring as a proximate result of any work undertaken under the permit granted pursuant to this application.
Notify the Administrative Authority at least twenty-four (24) hours in advance of the time when work will be started.
Comply with all applicable City Ordinances, the terms and conditions of the permit and all applicable rules and regulations of the City of
c La Quinta and to pay for any additional replacement necessary as the result of)this work.
Signature of Applicant or Agent
CVWD (Javier Villarreal), P.O. Box .1058. Coachella, CA 92236 (760) 396-2651 x3605
Name of Applicant (please print) Business Address Telephone No.
Same as above .
Name of Contractor and Job Foreman Business Address Telephone No.
Contractor's License No. City Business License No.
Applicant's• Insurance Company Policy Number
FEES: Subdivision, Improvement Permit — Class III
Public improvements: 3% of estimated construction costs Q
Private improvements: 3% of estimated construction costs
Minor. Improvement Permit — Class IV: See attached schedule
Inspection Fee $ 0.00
Permit Fee 0.00
Penalty 0.00
Cash Deposit -Surety Bond 0.00
if required
r
r TOTAL: $ 0.00
Receipt No.
Received by
Date
.4170
PERMIT VALIDATION
PERMIT NO. 4170
DATE APPROVED 6/25/04
EXPIRATION DATE 6/ - — -
s
_DATE ISSUED �- �•� ?
By
Administrative Authority
Recorded by
I
_r . Telephone: (760) 777-7075
r
r r
.Date: (e Ir�S �(%I • _ ,: ' - - :.
Location of Construction: ro v'
r
- � tiJ: ,�c r � .�--� 4-1 : fie_ • .. • ..
Dimension of Installation or Removal:.:
Approximate Construction Start Date:
Approximate Construction. Completion Date:
Estimated Construction Cost: $ -
.- Estimated Construction Cost shall include the removal of all obstructions, materials, and debris, back -filling; compaction and
' placing permanent resurfacing and or replacing improvements r
h
•�' ',
tip. -• '..
-Contact=Name:.: _ G✓ Phone Number:
Name,of Applicant.
,-Applicant Address: f -
•-Applicant Telephone Numben . 399a 6X'/ C---XT ?j<6 r— o2 Irtd2L a.?2 Z.65
..,
Name of Contractor: .
Contractor Address: d
Contractor Telephone Number: 41
Contractor. State License Number: f
Contractor:City Business License Number: i
► A COPY OF THE CURRENT INSURANCE`CERTIFICATEMUST BE PROVIDED
Applicant or Contractor General Liabilit-VInsurance Company:
.Applicant or Contractor General Liability Insurance Policy Number. -
•. - • - —.
Office Use Only: '
Assigned Permit Number: "
Approval Date:
• Expiration ,
Date: - e �t ✓ _ +
Issue
Date'
Administrative Authority-.
d �
0
9'
r.
i
�pTEq ;
DISTRIG�
.COACHELLA VALLEY WATER DISTRICT '
JAVIER VILLARREAL S
• COLLECTIONS SYSTEMS
SANITATION DIVISION
>I
pp. BOX 1058, COACH-ELLA, CALIF. 92236
TELEPHONE: (760) 398-2651
f �
%:i
i
�pTEq ;
DISTRIG�
.COACHELLA VALLEY WATER DISTRICT '
JAVIER VILLARREAL S
• COLLECTIONS SYSTEMS
SANITATION DIVISION
>I
pp. BOX 1058, COACH-ELLA, CALIF. 92236
TELEPHONE: (760) 398-2651
f �
%:i
f. NOTE:
With "o` er validatio n g'Q
Pr P r 04 -
;,' this form constitutes an CITY OFe CA. QUINTA
encroachment permit . ,.
APPLICATION FOR PERMIT
PUBLIC WORKS CONSTRUCTION (ENCROACHMENT)
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers, water mains
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
Lr P' Subdivision Improvement Permit -Class I I I
DATE: June 25, 2004 \ Minor Improvement Permit Class IV '
LOCATION OF CONSTRUCTION Jefferson 6 Avenue --On Jefferson ,(West'side)
e
(Street address or Description of Location) -
PURPOSE OF CONSTRUCTION Open-6 close gate valves Sketch (attach construction plans if appropriate)
DESCRIPTION OF CONSTRUCTION Ensure gate valves are open
*See Attached ions*
r DIMENSION OF INSTALLATION: OR REMOVAL N/A,*`)hrtc�- Wei �ue..f j : qAf,-3pP1
I` SIZE OF EXCAVATION, IFEEDED N/A Z) ^S2" W WAN Mw�..� SD
'Nr
C.
APPROXIMATE TIME WHEN WORK WILL BEGIN June • 26, 2004 .31 (
APPROXIMATE TIME OF COMPLETION June •26, 2004 / f1
ESTIMATED CONSTRUCTION COST $ C ,. SA- 0 Z �
(Including removal of all obstruction, materials, and debris, backfilling, com- J
,paction and placingpermanentresurfacing and/or replacing improvements)
In consideration of the granting of this,permit, the applicant hereby agrees to:
• Indemnify, defend and save the City; its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or court action and arising out of any accident, loss or damage to persons or property
happening or occurring as,a proximate result of any work undertaken under the permit granted pursuant to this application. ,
Notify -the Administrative Authority at least twenty'four (24) hours in advance ofthe time when work will be started. -
Comply with all applicable City Ordinances, the terms and conditions of the perm9t and all applicable rules and regulations of the City of `
La Quinta and to pay for any additional replacement necessary as the repik o this work.
' lgnature of Applicant or Agent
I
CVWD (Javier Villarreal), P.O. Box 1058, Coachella, CA 92236 (760)• 398-2651 x3605
Name of Applicant (please print) Business Address Telephone No.
Same as above'
Name of Contractor and Job Foreman Business Address Telephone No.
Y Contractor's License No. "• City Business License No.
'Applicant's Insurance' Company Policy Number `
FEES: Subdivision Improvement, Permit - Class III -
Public improvements: 3%of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit - Class IV: See attached schedule "
-N.! 4170
Ins
ee
-ti-n F $ 0.00
pe . PERMIT VALIDATION
Permit Fee 0.00 4170
PERMITNO.
Penalty 0.00 6 / 25 / 04
Cash Deposit -Surety Bond DATE APPROVED
if required' 0.00 6/25/01
• EXPIRATION DATE
TOTAL: $ .0.00
DAT ISS ED 6 _� - b •
Receipt No.
By
Received by Date Administrative Authority,
Recorded by Telephone:. (760) 777-7075